PATIENT DEMOGRAPHICS

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PATIENT DEMOGRAPHICS First Name M.I. Last Name Social Security - - Sex F M Birth / / Marital Status E-Mail Address Street Address City State Zip code Home Phone ( ) Work Phone ( ) Cell Phone ( )

1 PATIENT DEMOGRAPHICS First Name M.I. Last Name Social Security - - Sex F M Birth / / Marital Status Address Street Address City State Zip code Home Phone ( ) Work Phone ( ) Cell Phone ( ) Race: Ethnicity: American Indian or Alaska Native Hispanic Asian Not Hispanic Black or African American Not Specified Native Hawaiian or other Pacific Islander White Not Specified Employed: FT/PT/None - Employer Primary Language Primary Care Physician Pharmacy of Choice Are you diabetic? Yes No If yes, name of physician managing diabetes _ How did you hear about our practice? Health Fair Doctor Referral Internet Ad (Source ) Friend/Family Member/Patient (Name: ) Other: Emergency Contact Relationship to Patient Cell Phone Number ( ) Alternate Phone Number ( ) Financially Responsible Person First Name Last Name Social Security - - Sex F M Birth / / Street Address City State Zip code Home Phone ( ) Work Phone ( ) Cell Phone ( ) Insurance Information A. Insurance Company: Insurance ID Number: Subscriber Name: Subscriber Birth : Relationship to Patient: B. Insurance Company: Insurance ID Number: Subscriber Name: Subscriber Birth : Relationship to Patient: Patient's Authorization and Assignment of Benefits: I hereby authorize the processing of the medical insurance either by electronic or manual method by Garden State Foot Care. My signature authorizes payment for all major medical and/or durable medical equipment supplies and/or surgical benefits to which I am entitled from the listed insurer(s) above and/or by providing my insurance cards to the office to pay for services rendered to Garden State Foot Care. I certify that the information, I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information for this or any related claims. I permit a copy of this authorization to be used in place of the original. This authorization may be revoked by me at any time in writing. I recognize my financial obligation of any balance, co-insurance, deductible, and non-covered services that may be required. Signature of Responsible Party Relationship if not patient:

2 MEDICAL FORM Patient Name Birth Last First MI Age Height Weight Shoe Size Reason for your visit: How long has this been a problem? When does it occur? Morning Afternoon Evening Off and On All Day Please list previous treatments (either prescribed or home remedies): List current sports/activities: Do you have a history of allergies/skin reaction/sickness following the administration of any of the following: Y N ** If yes, list REACTION Adhesive tape Anesthesia Aspirin Caffeine Codeine Cortisone Demerol Please list (or attach a list) of your current medications and their dosages: Medical History: please circle P (personal history) and/or F (family history). P F Alcohol/Drug addiction/dependency P F GERD (Reflux) / GI ulcers (circle) P F Alzheimer's/Dementia P F Headaches / Migraines P F Anemia type P F Hearing Problems P F Arrhythmias type P F Heart Disease P F Arthritis - type P F Hepatitis A B C /Liver Disease P F Asthma circle (adult or childhood) P F High Blood Pressure P F Bleeding/Clotting Problems type P F High Cholesterol P F Cancer - type P F HIV/ Aids/ ARC P F Depression /Anxiety disorder/bipolar P F Kidney/ Renal Disease depression/other P F Lung Disease/Pulmonary Embolus P F Diabetes (how long? ) P F Lyme's Disease P F Emphysema / COPD P F Nervous Condition (type?) P F Glaucoma P F Osteoporosis / Osteopenia (circle) P F Gout P F Phlebitis (blood clots in legs) Y N ** If yes, list REACTION Foods Iodine Latex Local Anesthetics Penicillin Sulfa Drugs Other, please list: P F Poor Circulation / PVD P F Rheumatic Fever / Scarlet Fever P F Schizophrenia P F Seizures / Epilepsy P F STD s (sexually transmitted ds.) P F Sickle Cell Trait/Disease P F Stroke / TIA s P F Thyroid Problems (Hyper Hypo ) P F Tuberculosis P F Other, Please Specify P F Other, Please Specify P F NONE of the above Have you been hospitalized? Y N Please list Have you ever had surgery? Y N Please list Social History: PLEASE FILL OUT COMPLETELY SMOKING: Do you or have you ever smoked? YES NO If yes, how many years? How long ago did you quit? ALCOHOL USE: Do you or did you ever drink alcoholic beverages? YES NO How many drinks will you consume in a day? Week? How long ago did you quit? RECREATIONAL DRUG USE: Do you or have you ever used illicit/recreational drugs? YES NO If yes, which ones? How long ago did you quit? Women: Are you currently pregnant? YES NO Due date? Consent for Treatment: I certify that the information above is true and correct to the best of my knowledge. I have been informed that if I am uncertain about any question on the form I should ask the doctor or a member of the office staff for assistance. By signing below, I hereby authorize Garden State Foot Care to obtain medication history from community pharmacies and/or pharmacy benefit managers for the purpose of ongoing treatment. I give permission to Garden State Foot Care to administer and perform such procedures as may be deemed necessary in the diagnosis and/or treatment of my feet, ankles, and lower legs. Patient or Guardian Signature

3 Review of Symptoms Patient Name: Please check any of the following that you are currently experiencing or have recently experienced. Constitutional: Y N Musculoskeletal: Y N Do you feel fatigued during the day? Do you have low back pain? Do you have headaches? Do you have pain in your leg? Do you have a fever? Do you have foot pain? Do you have chills? Do you have joint pain? Do you have sweats? Do you have bone pain? Do you have malaise? Do you have general muscle aches or pains? Have you experienced any weight loss? Have you had swelling in your legs? Do you feel any dizziness/fainting spells? Have you had joint swelling or stiffness? Eyes: Y N Have you noticed a change in the way you walk? Do you wear glasses? Is it difficult to climb stairs? Do you wear contacts? Are you experiencing a loss of strength in your leg? Do you have blurry vision? Do you limp when you walk? Do you have burning eyes? Do your shoes wear out quickly or unevenly? Do you have itchy eyes? Integumentary (Skin): Y N Do you have sensitivity to light? Is your skin strongly sensitive when exposed to the sun? Are your eyes frequently red? Do you have any skin rashes? Do you have eye pain? Do you have any warts on your feet? Ears, Nose, & Throat: Y N Do you have any moles, lumps, or bumps on your skin? Do you have ringing in your ears? Do you have extremely dry skin or cracking? Do you get nosebleeds? Do you have open skin sores? Do you have difficulty swallowing? Are there unusual areas of discoloration on your skin? Cardiovascular: Y N Do you have any corns or calluses on your feet? Have you noticed your legs or ankles swelling? Are your nails unusually thick? Do you have cramping in your legs at night or at rest? Are your nails deformed? Do you have cramping in your legs/calf when walking? Are your nails ingrown and tender? Respiratory: Y N Do your nails cause you pain? Do you have chest pain? Do you have noticeable hair loss on your legs or feet? Do you have difficulty breathing? Neurological: Y N Do you have shortness of breath? Do you ever feel dizzy? Have you had a cough lasting longer than 3 weeks? Do you often feel confused or disoriented? Gastrointestinal: Y N Do you have problems with your balance? Do you have a loss in appetite? Do you have frequent or reoccurring headaches? Do you have increase in appetite? Do you have seizures? Does Aspirin cause stomach pain? Do you have tremors of your extremities? Do you have a history of stomach ulcers? Do your legs often feel like they are going to sleep? Do you have heartburn? Do you have numbness in your legs? Do you have bloody or dark stools? Do you have a feeling of burning in your legs? Genitourinary: Y N Do you have pain in the legs with walking or exercises? Do you have pain with urination (dysuria)? Do you have leg pain that is worse at night or rest? Have you noticed blood in your urine (hematuria)? Do you have leg pain all the times? Do you have any discharge? Do you experience shooting pains down your legs? Do you urinate more frequently than before? Do you have paralysis (complete loss of muscle strength in legs)? Do you have burning with urination? Psychiatric: Y N Hematologic/Lymphatic: Y N Do you have a history of psychiatric problems? Do you bruise easily? Are you subject to mood swings? Do you have any abnormal bruising? Are you under a lot of stress? Are you bleeding? Endocrine: Y N Allergic/Immunologic: Y N Are you excessively thirsty? If you get cut, does it take a long time to heal? Do you have a history of bad breath? Do you have allergic reactions to medication(s)? Are you experiencing night sweats? Do you have allergic reactions to foods? Do you have swollen glands? Do you have allergic reactions to dye? Have you had a significant weight change recently?

4 FINANCIAL POLICY Welcome to Garden State Foot Care and thank you for selecting our practice. We are committed to providing you with the best possible care. If you have medical insurance, we want to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our policy. 1. Your insurance is a contract between you, your employer, and the insurance company. It is your responsibility to understand the benefits of your plan. We cannot guarantee payment of your claims because your insurance company will not give us such guarantee. If your insurance company pays only a portion of your claim or rejects your claim, you and/or the policyholder should make an inquiry. Payment delays or rejection of your claim by your insurance company does not relieve the financial obligation you have incurred. Balances older than 30 days are subject to $5.00 per month fee. Returned checks are subject to a $35.00 fee. These fees are intended to cover costs incurred by our office. 2. We participate in a number of health insurance plans. All patients are required to pay their co-pay at time of check in. Patients that do not pay their co-pay at time of visit will be charged an additional $5.00. In addition, HMO patients must present a valid referral/authorization from their primary physicians at check in. All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be "not covered" or you do not have an authorization, you wll be responsible for the entire charge. We will attempt to verify benefits for some specialized services; however you remain responsible for charges to any service rendered. Patients are encouraged to contact their insurance company for clarification of benefits prior to services rendered. 3. MEDICARE PATIENTS Please understand that we participate with Medicare. However, you are responsible for your co-insurance, deductible, and any non-covered services. If Medicare has provided reimbursement for services rendered, and if your supplemental insurance does not respond within 30 days, then you become responsible for the balance. 4. Filings of insurance claims are a courtesy that we extend to our patients and all charges are your responsibility. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. We accept cash, check and all major credit cards for payment. 5. Missed appointments: You will be billed a $40.00 charge for missed appointments not cancelled with at least 24 hours notice. 6. If you believe your insurance company has erred or not adequately addressed your claims, you may contact the insurance company and/or file a grievance or appeal with the Insurance Administration in your state. I,, have read and I understand the above financial policies. These policies (Name of patient) are subject to change without prior written confirmation. Signature of patient or legal representative

5 SUMMARY NOTICE OF PRIVACY PRACTICES The Notice of Privacy Practices contains a detailed description of how our office will protect your health information, your rights as a patient and our common practices in dealing with patient health information. Uses and Disclosures of Health Information. We will use and disclose your health information in order to treat you or to assist other health care providers in treating you. We will also use and disclose your health information in order to obtain payment for our services or to allow insurance companies to process insurance claims for services rendered to you by us or other health care providers. Finally, we may disclose your health information for certain limited operational activities such as quality assessment, licensing, accreditation and training of students. Uses and Disclosures Based on Your Authorization. Except as stated in more detail in the Notice of Privacy Practices, we will not use or disclose your health information without your written authorization. Uses and Disclosures Not Requiring Your Authorization. In the following circumstances, we may disclose your health information without your written authorization: To family members or close friends who are involved in your health care; For certain limited research purposes; For purposes of public health and safety; To Government agencies for purposes of their audits, investigations and other oversight activities; To government authorities to prevent child abuse or domestic violence; To the FDA to report product defects or incidents; To law enforcement authorities to protect public safety or to assist in apprehending criminal offenders; When required by court orders, search warrants, subpoenas and as otherwise required by the law. Patient Rights. As our patient, you have the following rights: To have access to and/or a copy of your health information; To receive an accounting of certain disclosures we have made of your health information; To request restrictions as to how your health information is used or disclosed; To request that we communicate with you in confidence; To request that we amend your health information; To receive notice of our privacy practices. If you have a question, concern or complaint regarding our privacy practices, please contact: Teri Lodge, Administrator at or gardenstatefootcare1@gmail.com I,, acknowledge that I was provided a copy of the Notice of Privacy Practices (Name of patient) and that I have read or had the opportunity to read if I so chose and understood the Notice. By signing below, I hereby authorize Garden State Foot Care to obtain Medication History related to the patient above. In addition, I authorize the following, access to my personal health information upon request. Signature of patient or legal representative

PATIENT DEMOGRAPHICS First Name M.I. Last Name DOB Street Address City State Zip code Home Phone Work Phone Cell Phone Address Gender Married

PATIENT DEMOGRAPHICS First Name M.I. Last Name DOB Street Address City State Zip code Home Phone ( ) Work Phone ( ) Cell Phone ( ) E-Mail Address Gender! F! M Marital Status! Married! Divorced! Separated!